Synopsis The pilot of the helicopter had taken off from a fishing camp on George River, Quebec, on a night visual flight to Kuujjuaq, Quebec, 94 statute miles to the west-southwest. The flight was a medical evacuation (MEDEVAC) in response to a medical emergency, to transport a seriously injured woman. When the aircraft did not arrive at its destination at the expected time, a search was begun. The helicopter was found five days later; it had struck the ground in a steep dive. The four occupants were killed instantly. The Board determined that, while on a night MEDEVAC flight, the pilot likely lost his spatial orientation when he continued the flight in adverse flight conditions which he was not able to recognize in time because of the low light level. Contributing factors to the accident were that the pilot was not qualified for night flight or for instrument flight, and that the patient's condition likely influenced the pilot's decision to undertake the return night flight to Kuujjuaq for humanitarian reasons. 1.0 Factual Information 1.1 History of the Flight On 24 September 1994, an AS 350B helicopter belonging to Hli-Harricana, registration C-FPHI, left Kuujjuaq (CYVP), Quebec, at 1801 eastern daylight saving time (EDT)1 on a visual flight rules (VFR)2 flight. In response to a medical emergency, the pilot took a physician and a nurse from Kuujjuaq to a fishing camp on George River, 94 statute miles (miles) east-northeast of Kuujjuaq. The planned flight route involved flying over an area of tundra that is largely uninhabited. The helicopter landed at its destination in daylight at 1840. After the patient had been examined, the aircraft, with the pilot, a physician, a nurse and the patient on board, took off at about 1900 for Kuujjuaq under visual flight rules. At 1915, the crew of a First Air Boeing 727, FAB 867, relayed a message to the Kuujjuaq Flight Service Station (FSS) that the helicopter pilot expected to land in Kuujjuaq at 1955. At 1936, the pilot of C-FPHI informed the Kuujjuaq FSS that he was 42 miles from the airport and was delaying his arrival time to 2005. The FSS specialist gave him the weather information for Kuujjuaq, and the pilot acknowledged receipt of the information. That was the last communication received from the pilot. When the helicopter did not arrive at its destination at the expected time, a search was begun. The helicopter was found five days later; it had struck the ground in a steep dive, and had been destroyed by the impact. The crash occurred 38 miles northeast of Kuujjuaq, 2 miles south of the planned route. The pilot and the passengers died in the crash. The accident occurred at about 1939, in darkness, at latitude 5313'N and longitude 6722'W3. Night had fallen at 1907. 1.1.1 Additional Operational Information At about 1600 on 24 September 1994, a physician who was at Kangiqsualujjuaq (George River) was informed by radio that a woman had been seriously injured in a fishing accident two hours earlier. After assessing the injured person's condition through an intermediary, the physician judged it necessary to have her evacuated. He contacted the flight dispatcher of Johnny Mae Air Charters in Kuujjuaq to charter a float plane. The pilot of the aircraft declined the mission because it was not possible to complete the flight before nightfall. At about 1715, the flight dispatcher reached the pilot of C-FPHI, the accident helicopter, who agreed to make the flight. 1.1.2 Flight Planning The pilot and the flight dispatcher from Johnny Mae Air prepared an evacuation plan with two options. The first was to transport the patient to Kuujjuaq, if the flight could be completed before nightfall. The second option was to evacuate the injured woman to Kangiqsualujjuaq, where a twin-engined aircraft equipped and certified for night flight and instrument flight would take her to Kuujjuaq. The pilot decided to go to the fishing camp before deciding which option to take. The pilot went to Kuujjuaq airport at about 1730 to prepare the aircraft. The front left seat of the aircraft was removed and a hospital stretcher installed, and the medical equipment was placed on board. The helicopter took off with 3.4 hours of fuel on board. The pilot did not ask for a weather briefing or file a flight plan or flight notification with the FSS. The pilot did not report any anomaly on arrival at the fishing camp. He did mention to a witness that he would be going to Kangiqsualujjuaq if the flight could not be completed in daylight. A little later, after a brief conversation with the physician, he said that he was leaving for Kuujjuaq. The injured woman was held onto the stretcher by three straps. She was resting on the floor of the helicopter to the pilot's left, with her head to the back and her feet forward. The pilot occupied the front right seat, the physician the centre back seat, and the nurse the right back seat. 1.2 Injuries to Persons 1.3 Damage to Aircraft 1.4 Other Damage The other damage was limited to the trees and the ground at the accident site. 1.5 Personnel Information 1.5.1 General Information 1.5.2 Pilot Qualifications The pilot had obtained a commercial pilot licence (helicopter) on 08 March 1979. He was authorized to fly VFR in daylight only. He had passed a pilot proficiency check (PPC) on 01 June 1994. Before July 1987, candidates for commercial pilot licences (helicopter) did not have to carry out 10 hours of dual control instrument flight as has been required since that date. Pilots of helicopters and small aircraft are not required to demonstrate their instrument flight ability during the PPC. 1.5.3 Night Flying In daylight VFR, pilots rely on the presence of visual references outside the cockpit. Special piloting skills, different from those for visual flight, are required when those references are obscured. A night flight endorsement gives pilots the privilege of flying VFR at night. To obtain that endorsement, pilots must have taken a five-hour night course in a dual-control aircraft and must have flown five hours at night as pilot-in-command. Also, in order to prepare them for the possibility that they might inadvertently find themselves in instrument flight conditions (IMC), pilots must have received at least ten hours of training on basic instrument flight rules (IFR) flight manoeuvres. 1.5.4 Flying Experience The pilot had extensive experience on several helicopter types. He was familiar with the region in which the accident occurred. Nothing in his file indicates that he was in the habit of flying in visibility conditions lower than those prescribed by the existing regulations. The pilot's log-book, notebook, and personal files were used to assess his experience. The available information indicates that he had never been trained for either night flight or instrument flight. Thirteen days before the accident, on 11 September 1994, the pilot had made a return flight from Kuujjuaq to Kangiqsualujjuaq. He had left Kuujjuaq at 1747 and had returned at 1950, six minutes after the end of dusk. 1.5.5 Additional Training On 13 December 1988, the pilot had obtained a Transport Canada (TC) certificate stating that he had completed a course on pilot decision-making. The Pilot Decision-Making Training Program (PDP) was developed by TC to improve pilots' judgment through training. In February 1989, when he was employed by Hlicoptres Nordic Lte, the pilot had taken a company air safety officer course. The objective of this course was to train company pilots in the principles of managing air safety, so that companies could develop internal accident prevention programs. 1.5.6 Other Responsibilities The pilot had been hired by Hli-Harricana because he had extensive experience in helicopter flight and had also worked for a number of years in the sub-Arctic coastal zone of northern Quebec. The company had deployed two helicopters at Kuujjuaq at the beginning of the summer in order to develop a market in the region. Flights were carried out exclusively on an ad hoc basis. Although Kuujjuaq was not a Hli-Harricana base and the base manager duties were not defined, the pilot was acting as base manager. He was responsible for the proper operation of the company's affairs in the region. 1.6 Aircraft Information 1.6.1 General Information The single-engine, single-rotor helicopter was equipped with skids. C-FPHI was equipped with a global positioning system (GPS), a navigational device that can lighten a pilot's workload. The GPS data, including headings, speeds, times, ground speed, and so on, could be displayed on that instrument. The helicopter had neither an automatic pilot nor a stability augmentation system. 1.6.2 Helicopter Certification The aircraft was certified, equipped, and maintained in accordance with the existing regulations and approved procedures. The helicopter had the instruments necessary for IFR flight. However, this type of helicopter was not certified for IFR flight. According to Air Navigation Order, Series VII, No. 6, no air carrier shall operate a single-engined rotorcraft in IFR flight or at night when carrying passengers. 1.7 Meteorological Information The Board has conducted a study of VFR flight safety in adverse weather conditions4. The accident data make it possible to establish a direct connection between weather briefings and accident sites: helicopter accidents ... occurred in sparsely settled areas to experienced pilots who often did not have access to, or did not avail themselves of, weather briefing facilities.5 A weather briefing in preparation for a flight is indispensable before departure, especially at night when the ambient light level prevents a pilot from detecting the presence of adverse weather conditions before encountering them. 1.7.1 Meteorological Information Available at Kuujjuaq Airport An FSS staffed with FSS specialists was located at Kuujjuaq airport. The available services included: en route flight information service; flight planning service; surface weather observation service; and navigation assistance service. Contrary to his custom, the pilot did not use the weather facilities available to him and did not request a weather briefing before the flight. There is nothing in regulations that specifically obliges a pilot leaving on a VFR flight to obtain a weather briefing. Shortly after the take-off from Kuujjuaq, the FSS specialist transmitted to him the weather conditions in Kangiqsualujjuaq. Also, at the time of the last communication received from the pilot, the FSS specialist gave him the Kuujjuaq weather conditions. The pilot did not ask the FSS specialist to give him the regional forecasts, and the specialist did not transmit them to him. 1.7.2 1230 Area Forecast According to the area forecast, FACN3 CWUL, issued by the Quebec weather centre at 1230, there would be broken layers of cloud from 4,000 feet above sea level (asl) to 14,000 feet asl covering the area. Towering cumulus (TCU) and isolated altocumulus castellanus up to 16,000 feet asl were forecast, giving showers reducing visibility to between four and six miles with lower ceilings between 1,500 and 2,500 feet asl. At about 1900, or near the time of the occurrence, there would be a broken layer of cloud at between 2,000 to 3,000 feet asl and 18,000 feet asl covering the area. Frequent overlapping TCU up to 18,000 feet asl were forecast, giving showers reducing visibility to between two and six miles and lower ceilings, between 800 and 1,000 feet asl. 1.7.3 Analysis of Weather Conditions An analysis of the weather conditions was done by Environment Canada's Atmospheric Environment Service. All the information available for 24 September 1994 at the time of the occurrence indicates that in the region between Kuujjuaq and Kangiqsualujjuaq, the probable weather conditions were marginal for VFR flight (MVFR). Specifically, the conditions were probably as follows: clouds giving a ceiling between 2,000 feet and 3,000 feet asl; visibility of three to four miles in rain and fog; scattered clouds (stratus fractus) based at 1,000 feet asl and the possibility of a ceiling at that level; surface winds from the south at nearly 10 knots; significant wind shear between the surface and 1,000 feet, causing moderate turbulence; freezing level at 9,000 feet; and no form of icing. 1.7.4 Observed Meteorological Conditions At the camp, the cloud ceiling was estimated at 1,500 feet and visibility at two miles in fog. Before taking off from the camp for the return flight to Kuujjuaq, the pilot told a witness that the in-bound flight had taken place in conditions of drizzle and fog similar to those at the camp. A number of persons who were at the fishing camp witnessed the take-off. They saw the aircraft flying off toward the west before disappearing in the fog, drizzle, and darkness. About five minutes later, heavy showers from the west fell on the camp. Shortly after the expected arrival time of the helicopter, a twin-engined Piper PA28 Aztec flew to a point 30 miles east of Kuujjuaq, at the request of the FSS, in order to contact C-FPHI. The Aztec pilot reported encountering heavy showers in a very dark night. According to the regular observations, VFR conditions prevailed at Kuujjuaq for the duration of the flight up to the time of the occurrence. 1.7.5 Weather Conditions and Sensory Illusions When it is impossible to establish aircraft orientation by external reference to the ground or the horizon, a pilot must rely completely on aircraft flight instruments. Reliance on other than visual cues will quickly cause the pilot to lose his spatial orientation. According to a study published by the National Transportation Safety Board (NTSB)6, the predominant factor causing fatal accidents during MEDEVAC flights is the pilot's inadvertent continuation of VFR flight in weather conditions that require instrument flight (IMC); the majority of these accidents have occurred at night. The study also states that pilots inexperienced in instrument flight rarely succeed in overcoming spatial disorientation. 1.8 Aids to Navigation It was established that the pilot was in the habit of navigating using only the GPS, and that there was no aeronautical chart on board the aircraft. The Kuujjuaq airport was equipped with distance measuring equipment (DME), an instrument landing system (ILS), a very high frequency (VHF) omni-directional range (VOR), and a non-directional beacon (NDB). The Kangiqsualujjuaq airport had an NDB. The navigation systems on board the aircraft were capable of receiving the signals transmitted by the Kuujjuaq airport VOR. 1.9 Communications The pilot was able to communicate with the FSS or with other aircraft using a high frequency (HF) radio and a VHF radio. HF transmissions, unlike VHF transmissions, are not limited to visual range. Unfortunately, the HF was subject to atmospheric interference during the flight. This made the HF transmissions practically inaudible, and the pilot had to use VHF to ask the crew of FAB 867 to relay his expected arrival time to the FSS. The pilot did not declare an emergency or indicate that he was having any problems. The VHF air-ground communications systems functioned normally during the flight. The air-ground communications between the pilot and the FSS specialist were recorded on magnetic tape by Air Traffic Services (ATS). During a helicopter flight following the accident, the TSB verified the VHF radio range over the accident site. Two-way communication between the aircraft and the Kuujjuaq FSS was established from 500 feet asl. 1.10 Aerodrome Information 1.10.1 Kuujjuaq The airport is located just south of Kuujjuaq. Lighting systems were available for both runways. Because it is close to the town, the airport is easily located at night. 1.10.2 Kangiqsualujjuaq The airport at Kangiqsualujjuaq is located on the river bank downstream of the fishing camp and about 15 miles to the north. Lighting systems were available for the runway. 1.11 Flight Recorders The aircraft was not equipped with a flight data recorder (FDR) or a cockpit voice recorder (CVR), nor was either required by regulation. 1.12 Wreckage and Impact Information 1.12.1 General Information The accident site was on a magnetic heading of 111 degrees, 38 miles from Kuujjuaq. The helicopter was banked to the right when it crashed in a peat bog, at a nose-down angle of about 55 degrees. Pieces of the wreckage were lying on either side of a line on a magnetic heading of 195 degrees, or nearly 90 degrees to the left of the planned flight route. The debris was scattered over an area of about 340 feet by 150 feet. Although all the main components of the helicopter were found, some parts could not be located. Examination of the wreckage and the systems did not reveal any anomaly that could have hampered control of the aircraft before the collision with the ground. 1.12.2 Flight Instruments Microscopic examination of the vertical speed indicator dial showed the distinct imprint of a line left by the needle at the maximum downward reading, indicating a rate of descent of more than 2,000 feet per minute. Examination of the longitudinal and lateral inclination scales of the attitude indicator did not provide any indication as to the helicopter's attitude when it struck the ground for the first time. It was deduced that the attitude indicator was functioning at the time of impact, and, from that observation, that it was supplied with 28 volts DC. The GPS was recovered; unfortunately, the memory block had become detached from the supply block, so no information could be obtained from it. The filaments from the left and right rear navigation lights were intact. However, they had been stretched significantly, indicating that they were lighted or powered at the time of impact. Examination of the face of the airspeed indicator and the turn-and-slip indicator did not yield any reliable information. 1.12.3 Flight Controls The flight controls suffered major damage, and control continuity could not be confirmed. However, examination of all components recovered did not reveal any breakage or malfunction prior to impact. All breakages were attributed to overloads. 1.12.4 Engine The engine (Turbomeca-Ariel) was examined at the Turbomeca plant in Texas, in the presence of a U.S. National Transportation Safety Board (NTSB) investigator. The engine was turning at the time of impact; however, from the examination, it could not be determined how much power it was developing. 1.13 Medical Information 1.13.1 The Pilot There was no evidence that incapacitation or physiological factors affected the pilot's performance. His latest medical examination was in November 1993. His licence validation certificate was valid and did not bear any restriction. According to his medical file, the pilot had been consulting a lung specialist and an ear-nose-and-throat specialist since November 1992. He suffered from asthma and allergies that required him to carry adrenalin with him. Although the pilot should have reported these ailments to the civil aviation medical examiner, the civil aviation medical examination reports do not mention them. Section 6.5 of the Aeronautics Act requires a pilot to identify himself or herself as the holder of a pilot licence before being examined by a physician. Section 6.5 also requires the examining physician to inform the Minister of Transport if the patient has a condition that is likely to constitute a hazard to aviation safety. The section further states that a pilot is deemed to have consented to have the physician inform the Minister of any finding concerning his condition that relates to aviation. 1.13.2 The Patient The autopsy was not able to distinguish between the injuries suffered by the patient in the fishing accident and those caused by the crash. However, it was established that she had suffered serious injuries that required two intravenous drips before the flight. The patient was weak but calm when she was placed in the helicopter. 1.14 Fire Inspection of the accident site and examination of the wreckage and the engine yielded no evidence that there had been a fire during the flight. The fuel tank was ejected upon impact. A number of small fires ignited after the impact but went out on their own. 1.15 Survival Aspects The accident was not survivable because of the high impact forces. 1.15.1 Search and Rescue The emergency locator transmitter, which was mounted in the nose of the helicopter, was destroyed on impact. The aircraft was reported missing 25 minutes after its expected arrival time. The Canadian Forces were responsible for the search and rescue service. Five Canadian Forces aircraft and many civilian aircraft took part in the search. The helicopter was found five days after the accident, approximately five miles from its last known position. 1.16 Hli-Harricana Inc. 1.16.1 Organizational and Management Information Hli Forex Inc., a company that operates under the names Hli Forex and Hli-Harricana, is an air carrier offering helicopter charter service to the public. The company's operations are administered from its main base at Val d'Or, which includes offices, maintenance facilities, and support personnel. According to the company hierarchy, pilots reported to the chief pilot, who reported to the director of operations. The director of operations was responsible for flight safety. The responsibilities of base manager were not defined. 1.16.2 Hli-Harricana Procedures Hli-Harricana was authorized to operate its aircraft by day in VFR conditions only. The company had prepared an operations manual to help its operational personnel carry out their duties. The standards, practices, procedures, and specifications reflected the company's operating policies and were in compliance with government acts and regulations. All operational personnel were required to know and apply the procedures described in the operations manual. The operations manual was in the aircraft at the time of the accident. The company had not established a specific procedure for MEDEVAC flights, and none was required. The NTSB7 analyzed the effect of a mission on a pilot's judgement and concluded that pilots are occasionally subject to strong pressure to complete a MEDEVAC flight and that the support provided by the operator plays a decisive role in safety: The power of the mission itself to influence and perhaps override an EMS pilot's judgement is enhanced by the lack of a strong managerial structure to support the pilot in the working environment. 1.16.3 Pilot Responsibilities Article 3.2.4, PILOT-IN-COMMAND, of the company's operations manual stipulates that before take-off, the pilot must familiarize himself with the planned route and the weather forecasts for the flight. Also, article 3.2.4.1 of the operations manual, PILOT-IN-COMMAND In-Flight, states the following: In the course of the flight the pilot-in-command shall ensure that: a) the aircraft is operated in accordance with the Rules of the Air. When, however, an emergency arises, endangering the safety of the aircraft or persons, that necessitates action in contravention of regulations or procedures the pilot shall take such actions as he judges to be appropriate in the interest of safety. He shall notify the appropriate local authority of the deviation without delay; ... 1.17 Regulatory and Operational Framework for MEDEVAC Flights 1.17.1 Transport Canada (TC) and MEDEVAC Flights TC does not recognize transfers of patients as specialized flights and has not drafted specific standards for MEDEVAC flights. The Aeronautics Act does not provide for any deviation from the weather minimums and VFR night flights for MEDEVAC flights. 1.17.2 Comparison Between the Management of MEDEVAC Flights in Quebec and in Ontario Each province administers its MEDEVAC flight program according to its own standards and procedures. 1.17.2.1 MEDEVAC Flights in Quebec Quebec operates aircraft dedicated to transporting patients from remote areas who need care that is available only in a specialized hospital. However, as in most provinces, there is no infrastructure for managing first response and on-scene assistance MEDEVAC flights. The Health ministry has neither operating policies nor standards for this type of flight. In general, first response and on-scene assistance MEDEVAC flights are made on an ad hoc basis according to the existing air regulations. Typically, a person or agency that decides to carry out an emergency evacuation of a patient contacts the operator of its choice directly. The operational decision as to whether to undertake the flight is then up to the pilot. The pilot is responsible for flying the aircraft in such a way as to ensure that passengers are carried in complete safety and in accordance with the existing regulations. However, in remote areas, where sick and seriously injured persons can be evacuated only by air, pilots are likely to be faced with serious moral dilemmas when they judge that a flight can be carried out only in contravention of the regulations. 1.17.2.2 MEDEVAC Flights in Ontario Ontario has a first response and on-scene assistance MEDEVAC system administered by the Ministry of Health. In short, all requests for MEDEVAC flights are assessed and processed by the Medical Air Transport Centre, a flight regulation centre located in Toronto. Centre staff gather the information on the patient and make the necessary arrangements to have a suitable aircraft transfer the patient. Specially equipped fixed-wing aircraft and helicopters dedicated exclusively to ambulance transport are based in five Ontario cities and operate 24 hours a day. These aircraft are under contract to the Ministry of Health. Also, a number of other aircraft are used on an ad hoc basis. The operators must comply with operating and safety standards stricter than those in the existing regulations and those used in the aviation industry. Twenty-three operators are approved for patient transport. In this way the Ministry of Health ensures that the aircraft are certified for this type of flight and that the flight crews are qualified to carry out the missions.